Distal humeral fracture occurs in two age groups, in younger age group secondary to high-energy trauma and elderly women as a result of relatively low energy trauma. This fracture needs perfect anatomical stabilization and early mobilization as compared to other intra-articular fractures. It is advisable to stabilize all displaced distal intra-articular fractures of the humerus in patients who are medically fit for regional anesthesia. Standard surgical techniques are used for fixation of both column using combination of reconstruction plates, dynamic compression plates, locking compression plates, with screws and K-wires. A brief discussion on surgical anatomy of distal humerus, radiographic evaluation, classification, conservative or surgical treatment such as surgical stabilization, position of patient, fracture exposure and fixation, and role of primary total elbow replacement have been presented in this chapter. Primary total arthroplasty of the elbow also has its own distinct roles in the treatment of distal humerus fractures in elderly population with severe articular comminution, and bone loss, although the proper indications must be recognized.